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Community Health Connections Behavior Health Clinical Care Management in Fitchburg, Massachusetts



We are a Non-Profit Federally Qualified Healthcare Center located in Central Massachusetts. Our company opened in February 2002 in response to a Community Needs Assessment that identified a need for medical service for the underserved members of our community. We strive to provide compassionate care regardless of income or insurance status to everyone who walks through our doors, including low income, underinsured, uninsured, publicly housed, and homeless populations. CHC is committed to fostering, cultivating and preserving a culture of diversity, equity, and inclusion. At CHC, we strive for a workforce that reflects the community we serve. We are proud to be able to serve our community! If you are passionate about the work we do here, we would love to hear from you!

Behavioral Health Care Management position will conduct comprehensive assessments and facilitate medication reconciliation with pharmacist and/or primary care team.

Major responsibilities:

  • Conducts Comprehensive Assessments

  • Facilitates medication reconciliation with pharmacist and/or primary care team.

  • Engages members and care givers in active care planning with a focus on, medical, behavioral, social, member-centered care needs. Coaches and guides member/representative to meet bio/psycho/social care goals.

  • Provide care coordination, which may include but is not limited to facilitating care transitions, supporting the completion of referrals, and/or providing or confirming appropriate follow-up

  • May be required to meet members while they are inpatient to provide education and support about the discharge process and transition the member into care management.

  • Travel throughout assigned area to engage members at their homes or other locations where the member may be located.

  • Assesses the member’s knowledge of their medical, behavioral health and/or social conditions and provides education and self-management support based on the member’s needs and preferences.

  • Connects members with primary care, behavioral health, flexible services, Community Partner, respite, and other community based social services as indicated and appropriate.

  • In collaboration with Community Health Workers creates and maintains a comprehensive inventory of local community resources through a web-based application, improving accessibility for members and providers, and linking members with the appropriate support services.

  • Participates in the integrated care team meetings and rounds as required.

  • Maintain accurate, timely documentation in electronic systems including health center EHRs.

Minimum Qualifications:

  • 2-3 years of Inpatient or Community Social Work experience providing patient-centered outreach, behavioral health services, needs assessment and support.

  • Bachelor's Degree required, master's degree in psychology, Social Work or related field preferred.

  • Licensed Clinical Social Worker (LCSW or LICSW), or Licensed Mental Health Counselor (LMHC) preferred but not required in lieu of experience.

  • Demonstrated success in working as part of a multi-disciplinary team including communicating and working with Providers, Nurses, Community Health Workers, and other health care teams.

  • Ability to flexibly utilize clinical expertise to solve complex problems.

  • Bi-lingual

  • Experience working with patients with chronic and behavioral health needs.

  • Must be flexible and adaptable to change.

  • Demonstrate the ability to work independently.

  • Must demonstrate excellent interpersonal communication skills.

  • Additional qualities that would be a good fit for our team include enthusiasm and passion for helping patients, genuine spirit, kind, and empathetic nature, and one who embraces a ‘go with the flow’ mentality.

  • Experience using appropriate technology, such as computers, for work-based communication.

  • Experience and proficiency with Microsoft Office and online record keeping.

  • Experience working with a Medicaid population is strongly preferred.

  • Experience working with Federally Qualified Health Centers is strongly preferred.

  • A valid driver's license and provision of a working vehicle

  • Experience with anti-racism activities, and/or lived experience with racism is highly preferred.


  • 401k

  • Generous vacation and personal time for eligible employees

  • Sick time

  • Medical, dental, and vision insurance

  • 100% paid Life insurance/AD&D

  • 100% paid Long-Term disability.

  • Employee Assistance Program (EAP)

  • Discounts on travel and entertainment!

  • Discounts on cell phone service, computer purchases, and more!

  • College Tuition Rewards/CMEs

  • Company Events & Activities (Annual cookout and holiday party, health and wellness events,” Lunch & Learn’s”, team building, and more!)

  • Employee Assistance Program (EAP)

  • EyeMed Vision Care Program

  • Accident & Cancer Insurance

  • Educational development reimbursement

  • Discounts on - gym membership, travel & entertainment tickets, electronics, and more!